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Marcelli V, Giannoni B, Volpe G, Faralli M, Fetoni AR, Pettorossi VE. Downbeat nystagmus: a clinical and pathophysiological review. Front Neurol 2024; 15:1394859. [PMID: 38854962 PMCID: PMC11157062 DOI: 10.3389/fneur.2024.1394859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Accepted: 04/29/2024] [Indexed: 06/11/2024] Open
Abstract
Downbeat nystagmus (DBN) is a neuro-otological finding frequently encountered by clinicians dealing with patients with vertigo. Since DBN is a finding that should be understood because of central vestibular dysfunction, it is necessary to know how to frame it promptly to suggest the correct diagnostic-therapeutic pathway to the patient. As knowledge of its pathophysiology has progressed, the importance of this clinical sign has been increasingly understood. At the same time, clinical diagnostic knowledge has increased, and it has been recognized that this sign may occur sporadically or in association with others within defined clinical syndromes. Thus, in many cases, different therapeutic solutions have become possible. In our work, we have attempted to systematize current knowledge about the origin of this finding, the clinical presentation and current treatment options, to provide an overview that can be used at different levels, from the general practitioner to the specialist neurologist or neurotologist.
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Affiliation(s)
- Vincenzo Marcelli
- Audiology and Vestibology Unit, Department of ENT, Ospedale del Mare, ASL Napoli 1 Centro, Napoli, Italy
- Department of Neuroscience, Reproductive Science and Dentistry, Section of Audiology, University of Naples ‘’Federico II’’, Napoli, Italy
| | - Beatrice Giannoni
- Department of Neuroscience, Psychology, Drug’s Area and Child’s Health, University of Florence, Florence, Italy
| | - Giampiero Volpe
- Department of Neurology, Ospedale San Luca di Vallo della Lucania, ASL Salerno, Salerno, Italy
| | - Mario Faralli
- Department of ENT, University of Perugia, Perugia, Italy
- Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Anna Rita Fetoni
- Department of Neuroscience, Reproductive Science and Dentistry, Section of Audiology, University of Naples ‘’Federico II’’, Napoli, Italy
| | - Vito E. Pettorossi
- Department of Medicine and Surgery, University of Perugia, Perugia, Italy
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Martins AI, Jorge A, Lemos J. Central Positional Nystagmus. Curr Treat Options Neurol 2022. [DOI: 10.1007/s11940-022-00731-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Zhou DJ, Pavuluri S, Snehal I, Schmidt CM, Situ-Kcomt M, Taraschenko O. Movement disorders associated with antiseizure medications: A systematic review. Epilepsy Behav 2022; 131:108693. [PMID: 35483204 PMCID: PMC9596228 DOI: 10.1016/j.yebeh.2022.108693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 03/14/2022] [Accepted: 03/31/2022] [Indexed: 11/19/2022]
Abstract
New-onset movement disorders have been frequently reported in association with the use of antiseizure medications (ASMs). The frequency of specific motor manifestations and the spectrum of their semiology for various ASMs have not been well characterized. We carried out a systematic review of literature and conducted a search on CINAHL, Cochrane Library, EMBASE, MEDLINE, PsycINFO, and Scopus from inception to April 2021. We compiled the data for all currently available ASMs using the conventional terminology of movement disorders. Among 5123 manuscripts identified by the search, 437 met the inclusion criteria. The largest number of reports of abnormal movements were in association with phenobarbital, valproic acid, lacosamide, and perampanel, and predominantly included tremor and ataxia. The majority of attempted interventions for all agents were discontinuation of the offending drug or dose reduction which led to the resolution of symptoms in most patients. Familiarity with the movement disorder phenomenology previously encountered in relation with specific ASMs facilitates early recognition of adverse effects and timely institution of targeted interventions.
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Affiliation(s)
- Daniel J Zhou
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, United States
| | - Spriha Pavuluri
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, United States
| | - Isha Snehal
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, United States
| | - Cynthia M Schmidt
- Leon S. McGoogan Health Sciences Library, University of Nebraska Medical Center, Omaha, NE, United States
| | - Miguel Situ-Kcomt
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, United States
| | - Olga Taraschenko
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, United States.
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Tran TM, Lee MS, McClelland CM. Downbeat nystagmus: a clinical review of diagnosis and management. Curr Opin Ophthalmol 2021; 32:504-514. [PMID: 34456290 DOI: 10.1097/icu.0000000000000802] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW This review will extensively cover the clinical manifestations, causes, diagnostic evaluation, and management strategies of downbeat nystagmus (DBN). RECENT FINDINGS Historically, MRI to assess for structural lesions at the cervicomedullary junction has been the primary diagnostic test in the evaluation of DBN since the 1980s. In recent years, there is increasing awareness of nonstructural causes of DBN including gluten ataxia, nutritional deficiencies, and paraneoplastic syndromes, among others. Medical management with aminopyridines has become first-line therapy in addition to disease-specific therapies. SUMMARY DBN is a common form of acquired nystagmus and the differential diagnosis remains broad, including both benign and potentially fatal causes. For practical purposes, the causes can be categorized as structural vs. nonstructural with MRI as the ideal, initial diagnostic study to differentiate the two. General therapeutic options include pharmacotherapy to enhance Purkinje cell function, strabismus surgery or prisms to shift null points, and behavioural changes. Disease-specific treatment is necessarily broad, though a significant proportion of patients will be idiopathic.
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Affiliation(s)
- Tu M Tran
- Department of Ophthalmology and Visual Neurosciences
| | - Michael S Lee
- Department of Ophthalmology and Visual Neurosciences
- Department of Neurology
- Department of Neurosurgery, University of Minnesota, Minneapolis, USA
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Choi JY, Kim JS. Central positional nystagmus: Characteristics and model-based explanations. PROGRESS IN BRAIN RESEARCH 2019; 249:211-225. [PMID: 31325981 DOI: 10.1016/bs.pbr.2019.04.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The central vestibular system operates to precisely estimate the rotational velocity and gravity orientation using the inherently ambiguous information from peripheral vestibular system. Therefore, any lesions disrupting this function can generate positional nystagmus. Central positional nystagmus (CPN) can be classified into the paroxysmal (transient) and persistent forms. The paroxysmal CPN has the features suggesting a semicircular canal origin regarding the latency, duration, and direction of nystagmus. Patients with paroxysmal CPN commonly show several different types of nystagmus classified according to the provoking positioning. The persistent form of CPN mostly appears as downbeat nystagmus while prone or supine, or apogeotropic or geotropic horizontal nystagmus when the head is turned to either side while supine. CPN may be ascribed to erroneous neural processing within the velocity-storage circuit that functions in estimating angular head velocity, gravity direction, and inertia. Paroxysmal CPN appears to be post-rotatory rebound nystagmus due to lesions involving the cerebellar nodulus and uvula. In contrast, persistent CPN may arise from erroneous gravity estimation. The overlap of lesion location responsible for both paroxysmal and persistent CPN may account for the frequent coexistence of both forms of nystagmus in a single patient.
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Affiliation(s)
- Jeong-Yoon Choi
- Department of Neurology, Dizziness Center, Clinical Neuroscience Center, Seoul National University Bundang Hospital, Seongnam, South Korea; Department of Neurology, Seoul National University College of Medicine, Seoul, South Korea
| | - Ji-Soo Kim
- Department of Neurology, Dizziness Center, Clinical Neuroscience Center, Seoul National University Bundang Hospital, Seongnam, South Korea; Department of Neurology, Seoul National University College of Medicine, Seoul, South Korea.
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Mucci V, Cha YH, Wuyts FL, Van Ombergen A. Perspective: Stepping Stones to Unraveling the Pathophysiology of Mal de Debarquement Syndrome with Neuroimaging. Front Neurol 2018; 9:42. [PMID: 29483889 PMCID: PMC5816028 DOI: 10.3389/fneur.2018.00042] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 01/17/2018] [Indexed: 01/07/2023] Open
Abstract
Mal de debarquement syndrome (MdDS) is a neurological condition typically characterized by a sensation of motion, which in most cases manifests after disembarking from a vehicle (e.g., boat, plane, and car). However, the same symptoms can also occur spontaneously. Two main theories of the pathophysiology of MdDS are briefly summarized here. In this perspective, we aimed to report the most recent findings on neuroimaging studies related to MdDS, as well as to suggest further potential research questions that could be addressed with the use of neuroimaging techniques. A detailed analysis of previous work on MdDS has led to five main research questions that could be addressed in new neuroimaging studies. Furthermore, in this perspective, we propose new stepping-stones to addressing critical research questions related to MdDS and its pathophysiology. We propose considerations for new studies, as well as a detailed analysis of the current limitations and challenges present when studying MdDS patients. We hope that our examination of the nuances of MdDS as a neurological disorder will contribute to more directed research on this topic.
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Affiliation(s)
- Viviana Mucci
- Antwerp University Research Centre for Equilibrium and Aerospace, Department of Biomedical Physics, Faculty of Sciences, University of Antwerp, Antwerp, Belgium
| | - Yoon-Hee Cha
- Laureate Institute for Brain Research, Tulsa, OK, United States
| | - Floris L Wuyts
- Antwerp University Research Centre for Equilibrium and Aerospace, Department of Biomedical Physics, Faculty of Sciences, University of Antwerp, Antwerp, Belgium
| | - Angelique Van Ombergen
- E.N.T., Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
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Could pregabalin cause oculomotor symptoms in lower dose? A case with down beat nystagmus as a side effect. Acta Neurol Belg 2017; 117:777-778. [PMID: 27988831 DOI: 10.1007/s13760-016-0735-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 12/07/2016] [Indexed: 10/20/2022]
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Singh R, Gandhi M, Naveed M, Pikale G. Dapsone-induced methemoglobinemia leading to nystagmus. JOURNAL OF CURRENT RESEARCH IN SCIENTIFIC MEDICINE 2017. [DOI: 10.4103/jcrsm.jcrsm_31_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Characteristics and mechanism of perverted head-shaking nystagmus in central lesions: Video-oculography analysis. Clin Neurophysiol 2016; 127:2973-2978. [DOI: 10.1016/j.clinph.2016.07.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 06/22/2016] [Accepted: 07/10/2016] [Indexed: 11/19/2022]
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Jeong SH, Kim YS, Lee JH, Jo H, Lee AY, Kim JM. Transient Positive Horizontal Head Impulse Test in Pregabalin Intoxication. J Epilepsy Res 2015; 5:101-3. [PMID: 26819943 PMCID: PMC4724849 DOI: 10.14581/jer.15017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 11/15/2015] [Indexed: 11/03/2022] Open
Abstract
Head impulse test (HIT) is helpful to understanding high-frequency vestibulo-ocular reflex in patients with dizziness and imbalance. There are some reports on abnormal HITs in cerebellar disorder. To our knowledge, there was no report of transient bilateral positive head impulse related to antiepileptic drugs. A 65-year-old woman developed dizziness and imbalance after treatment with pregabalin for pain control of radiation cystitis. Neurological examination exhibited positive bilateral HIT results, in addition to ataxia and gaze-evoked rebound nystagmus. Pregabalin intoxication can evoke transient positive horizontal head impulse test as another indicator of cerebellar dysfunction.
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Affiliation(s)
- Seong-Hae Jeong
- Department of Neurology, Chungnam National University Hospital, Daejeon, Korea
| | - Yong Soo Kim
- Department of Neurology, Chungnam National University Hospital, Daejeon, Korea
| | - Ju-Hoen Lee
- Department of Neurology, Chungnam National University Hospital, Daejeon, Korea
| | - Hyunjin Jo
- Department of Neurology, Chungnam National University Hospital, Daejeon, Korea
| | - Ae Young Lee
- Department of Neurology, Chungnam National University Hospital, Daejeon, Korea
| | - Jae-Moon Kim
- Department of Neurology, Chungnam National University Hospital, Daejeon, Korea
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Littlefield PD, Pinto RL, Burrows HL, Brungart DS. The Vestibular Effects of Repeated Low-Level Blasts. J Neurotrauma 2015; 33:71-81. [PMID: 25790248 DOI: 10.1089/neu.2014.3824] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The objective of this study was to use a prospective cohort of United States Marine Corps (USMC) instructors to identify any acute or long-term vestibular dysfunction following repeated blast exposures during explosive breaching training. They were assessed in clinic and on location during training at the USMC Methods of Entry School, Quantico, VA. Subjects received comprehensive baseline vestibular assessments and these were repeated in order to identify longitudinal changes. They also received shorter assessments immediately following blast exposure in order to identify acute findings. The main outcome measures were the Neurobehavioral Symptom Inventory, vestibular Visual Analog Scale (VAS) of subjective vestibular function, videonystagmography (VNG), vestibular evoked myogenic potentials (VEMP), rotary chair (including the unilateral centrifugation test), computerized dynamic posturography, and computerized dynamic visual acuity. A total of 11 breachers and 4 engineers were followed for up to 17 months. No acute effects or longitudinal deteriorations were identified, but there were some interesting baseline group differences. Upbeat positional nystagmus was common, and correlated (p<0.005) with a history of mild traumatic brain injury (mTBI). Several instructors had abnormally short low-frequency phase leads on rotary chair testing. This study evaluated breaching instructors over a longer test period than any other study, and the results suggest that this population appears to be safe from a vestibular standpoint at the current exposure levels. Upbeat positional nystagmus correlated with a history of mTBI in this population, and this has not been described elsewhere. The data trends also suggest that this nystagmus could be an acute blast effect. However, the reasons for the abnormally short phase leads seen in rotary chair testing are unclear at this time. Further investigation seems warranted.
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Affiliation(s)
- Philip D Littlefield
- 1 Department of Otolaryngology, Walter Reed National Military Medical Center , Bethesda, Maryland
| | - Robin L Pinto
- 2 Audiology and Speech Pathology Center, Walter Reed National Military Medical Center , Bethesda, Maryland
| | - Holly L Burrows
- 2 Audiology and Speech Pathology Center, Walter Reed National Military Medical Center , Bethesda, Maryland
| | - Douglas S Brungart
- 2 Audiology and Speech Pathology Center, Walter Reed National Military Medical Center , Bethesda, Maryland
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van Gaalen J, Kerstens FG, Maas RPPWM, Härmark L, van de Warrenburg BPC. Drug-induced cerebellar ataxia: a systematic review. CNS Drugs 2014; 28:1139-53. [PMID: 25391707 DOI: 10.1007/s40263-014-0200-4] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND OBJECTIVES Cerebellar ataxia can be induced by a large number of drugs. We here conducted a systemic review of the drugs that can lead to cerebellar ataxia as an adverse drug reaction (ADR). METHODS We performed a systematic literature search in Pubmed (1966 to January 2014) and EMBASE (1988 to January 2014) to identify all of the drugs that can have ataxia as an ADR and to assess the frequency of drug-induced ataxia for individual drugs. Furthermore, we collected reports of drug-induced ataxia over the past 20 years in the Netherlands by querying a national register of ADRs. RESULTS Drug-induced ataxia was reported in association with 93 individual drugs (57 from the literature, 36 from the Dutch registry). The most common groups were antiepileptic drugs, benzodiazepines, and antineoplastics. For some, the number needed to harm was below 10. Ataxia was commonly reversible, but persistent symptoms were described with lithium and certain antineoplastics. CONCLUSIONS It is important to be aware of the possibility that ataxia might be drug-induced, and for some drugs the relative frequency of this particular ADR is high. In most patients, symptoms occur within days or weeks after the introduction of a new drug or an increase in dose. In general, ataxia tends to disappear after discontinuation of the drug, but chronic ataxia has been described for some drugs.
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Affiliation(s)
- J van Gaalen
- Department of Neurology 935 and Donders Institute for Brain, Cognition, and Behaviour, Radboud University Medical Centre, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands,
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Beh SC, Frohman TC, Frohman EM. Neuro-ophthalmic Manifestations of Cerebellar Disease. Neurol Clin 2014; 32:1009-80. [DOI: 10.1016/j.ncl.2014.07.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Shin C Beh
- Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Teresa C Frohman
- Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Elliot M Frohman
- Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA; Department of Ophthalmology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA.
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